Conditions that Mimic Child Abuse Kathy Saunders, DNP-BC, FNP/PNP Skin Findings that Mimic Abuse Myths and Truths Myth You can accurately date a bruise based on its color 1
Truth As a bruise heals it may exhibit many colors Red, violet, black, yellow, green, brown No predictable order or chronology/dating of an injury based on color progression Truth (in 1991) A bruise with yellow in it is > 18 hours The other colors may appear from 1 hour after the injury until the resolution of the bruise Bruises of identical cause and age on the same person may not appear the same Langllos and Bresham, 1991 Truth (today) Timing of yellow bruising is unclear Accuracy of determination is <40% based on color of bruise Inter-observer reliability is poor you see color one way, someone sees it differently Do NOT use color to date a bruise Maguire, et al. 2005 2
Factors that affect the rate of bruise resolution Amount of: Extravascular blood Applied force to the body surface area Tissue damage Vascularity and location of the tissue Patient skin color and age Myth The skin overlying a fracture is typically bruised in cases of abuse Truth Peters, et al identified 1,992 children with inflicted skeletal fractures Main outcome measure was presence of bruising and fracture in a single body region or extremity often unrelated to site of fx 23.3% of children with skull fractures had associated bruising 3
Genital Findings that Mimic Abuse Myth Sexual abuse is a common cause of genital bleeding Truth Differential diagnosis of genital bleeding in a pre-pubertal child Trauma Genitourinary tract Gastrointestinal tract Dermatologic Conditions Infectious diseases 4
Straddle Injuries Accidental injury to the midline ano-genital structures Occurs when a child straddles a firm object as he/she falls Compression of soft tissues against bones in the pelvic region Most Common Forms of Injury Falling on a stationary object Straddling a bicycle Bath tub related Playground injury Straddling a pool Straddle Injuries - Genital Most cause damage to the soft tissues overlying the pubic symphysis, the labia, as well as the posterior fourchette and perineum Compared with injuries caused by abuse, straddle injuries are often unilateral They usually only cause damage to the external genitalia 5
Suspicious Straddle Injuries Extensive trauma: multi-site body injuries Non-ambulatory child: child less than 18 mts Coexisting non-genital trauma: PA Lack of correlation between history and physical findings Dowel, et al. 1994 Genitourinary Tract Urethral Prolapse Vaginal bleeding Urethral swelling Vaginal and urethral pain Typically occurs in young Black girls, age 4 8 years Factors Contributing to Urethral Prolapse Estrogen deficiency Large weight for age Trauma Urinary tract infection Anatomical defects 6
Urethral Prolapse Treatment Sitz baths Estrogen cream (Estrace) If symptoms are severe or persist, referral to a urologist may be necessary. Treat underlying urinary tract infection if present Gastrointestinal Tract Pinworm Dermatological Conditions Group A Strep Study summary: Most frequently reported vaginitis Puritis the most common symptom Erythema universally present Discharge infrequently Peak occurrence late winter/early spring 7
Physical Exam Clues Foul Smell: Foreign body, necrotic tumor Bleeding + DC: Group A strep, Shigella, FB Greenish DC GC, Group A Strep, FB Derm Conditions: Ulcerative Lesions Epstein-Barr virus: Mono ulcers up to 1.5cm- can do EB viral culture- often associated later with lymphadenopathy and fever Varicella Zoster: Chicken Pox or Shingles- First eruption of Chicken Pox can be on the vulva and mistaken for herpes *looks identical on Tzanck smear Coxsackie Virus: Can be associated with acute renal disease TREATMENT If specific infection, treat for that organism If treating empirically, options: 10 days Amoxil, Augmentin, Cephalosporins AB dose: TID dosing x week Diflucan 6 mg/kg/d initial and then 3mg/kg/d x 7 days 8
FOREIGN BODY - VAGINITIS A Study in Philadelphia: 192 prepubertal girls w/ GYN sx: FB present 4% 18% with vaginal bleeding w/ or w/o DC had FB 50% with bleeding and no DC had a FB LICHEN SCLEROSIS Appearance: White shiny macules that coalesce and form fine wrinkled skin- may form figure 8 pattern about the labia, perineum and perianal tissue Pruritic, hemorrhagic, > scaling, vesicules Lichen Sclerosis - Location Location Genital 75% of time Extragenital patches on the trunk and extremities- 10 20% of cases Oral lesion are frequently seen Can be confused with: herpes, Candida or strep 9
Lichen Sclerosis - Etiology Most cases are in postmenopausal females 10% cases appear in children usually under 7 yrs. CAUSE UNKNOWN suggested to be immunologic Lichen Sclerosis - Prognosis Prognosis: 50-70% resolve with puberty 18% may develop long term sequelae Development of malignancy in adolescents has been reported Lichen Sclerosis - Treatment Treatment: - Be aggressive Temovate 0.05% BID 2-4 weeks then HS x 2 weeks; then with flares (max. 60gm/6mths) If secondary infection, also treat Possible side-effects of steroids: Burning associated with erythema and edema Dilation of blood vessels-superficial 18% of cases (hemorrhoid appearance) After RX- Regular use of barrier ointments to prevent friction and reoccurrence 10
Lichen Simplex Appearance: localized thickening of skin Microscopically: Lesions are hyperkeratotic Treatment: Mid-potency topical steroids; oral antipruritics Inflammatory Dermatosis Seborrheic Dermatitis: Appearance- symmetric, erythematous lesions, oily scaly, indistinct borders, intense pruritus Secondary infections are common: Candida/Pityrosporum Extragental locations: scalp, hair, moist sites (diaper area, axillae) RX: low-potency topical steroids, antiseborrheic shampoos and Ketoconazole creams Inflammatory Dermatosis Eczema: Atopic Dermatitis Acute and Chronic stages Acute- erythema, scaling, vesicles, crusts Chronic- scaling, lichenification and pigmentary changes BOTH may present at different sites at the same time and the same site at different times during the course of the disease 11
Inflammatory Dermatosis - Eczema Distribution and morphology of skin lesions are DX Clinical findings show a characteristic pattern of evolution Infantile phase begins between 1-6 months and lasts 2-3yrs. Rash is red, itchy papules/plaques which ooze and crust. Diaper area is usually spared Inflammatory Dermatosis - Eczema Childhood Phase: Occurs between 4-10 yrs Circumscribed red, scaly plaques are symmetrically distributed Frequently see 2 nd infections intense scratching Most experience improvement during warm, humid summer months and exacerbations in the winter/fall 75% children improve by age 10-14yrs Inflammatory Dermatosis - Psoriasis Psoriasis: May begin as persistent diaper rash Eruption: bright red, scaly, well demarcated line May misdiagnose for Cnadida has no scales, but fungal exudate RX: topical steroid temporary improvement but lesions persist/recur for months 12
Labial Adhesions Incidence: 1-3% of all females 90% present before 6 yrs old and resolve at puberty 50% may resolve spontaneously over 6mts-1 year Labial Adhesion Differential DX: Imperforate hymen Scarring of labia 3/50 patients will have urologic abnorm Intersex problems Labial Adhesion RX: Estrace cream BID 2 weeks then HS 2 weeks (90% success rate) Maintenance- A & D oint., Vaseline HS TX with surgery if s/s 13
Cutaneous Mimics of Child Abuse Non-inflammatory conditions Inflammatory conditions Cultural practices Dermal Melanosis bluish gray skin coloration of the left upper extremity, including the thumb and middle finger, and on the right buttock in a full-term, African American Also called - -Mongolian Spots Impetigo The most frequent mimic of child physical abuse Honey-colored crust Streptococcus pyogenes and Staphylococcus aureus Spreads if untreated Wheeler and Hobbs, 1988 14
Impetigo Lesions have a thin yellow crust and can be different sizes. If the same cigarette is used on end to burn someone s skin, the lesions will be the same size or close to the same size every time. Cigarette Burn Vary from circular bullae to deep, punched out craters with raised edges Center of the burn typically the deepest 8 mm in diameter Document the dimensions of the lesions using a tape measure. Photo document the lesions or draw with Constriction Bands 15
Constriction Bands Cultural Practices Coin Rubbing Warm oil is applied to the skin Coin is vigorously rubbed on skin Stripes of petechiae in a geometric pattern Hulewicz, 1994 THE END QUESTIONS KSAUNDERS@SUMTERFHC.COM 16